Tuesday, August 25, 2009

Death Panels AKA Advanced Care Plan: I Finally Get It

For a long time, I really didn't understand the debate over so-called "death panels." I'd read the news. I'd read the text of the law. I'd gone back and forth, but never really got it. Now I see where the mistake was made, and why so many people are (incorrectly) upset. It's a subtle thing, but one that really can't be ignored. I finally got it when I read the recent FactCheck.org rebuttal to former New York Lt. Gov. Betsy McCaughey's comments on The Daily Show.

Here's what the crux of it is: the law (as it stands today) says that doctors can (mind you, *can*) report on some quality metrics and receive some extra payment from Medicare, above and beyond the normal payment. This amounts to a small (2%) bump in what they get paid, and they get to determine what quality metrics to report. There's just a requirement that the report on a minimum number of them. One of the (again, existing) metrics is having discussed how you want issues such as life support dealt with. Right now, that's it. You just have to report on the percentage of patients that you've had the conversation with and who have then either created appropriate documents or signed a statement saying that they don't wish to.

The new law, built into the health care reform legislation, would add a new criteria: you would also report on the percentage of times that those wishes are carried out. Therein lies the rub...

You see, this has been mis-interpreted as saying that doctors will be penalized (e.g. won't get that extra 2%) if they allow you to change your mind. This is not what the legislation says. What it says is that the doctor has to report on their enacting of the conditions of your advance care planning wishes. If you are conscious and able to communicate your wishes, then advance care planning doesn't enter into play, and thus no reporting would ever be necessary, but the way it's being portrayed is exactly the opposite.

Now, there are some gotchas. For example, you might become lucid; say "don't unplug me;" and then go back under. What now? The doctor has to decide if they should honor your stated wishes in writing or your stated wishes in person. Today, doctors and next of kin make that choice together (or should... law or no, there are always abuses). Under this law, nothing would change except for the after-the-fact review which doctors could choose to participate in or not.

This is the "death panel." An optional reporting system which considers any choice by the patient to be equally valid (e.g. your advance care planning documents might well request that every effort be made to maintain your vital statistics, and there's nothing wrong with that). Not much of a "death panel" is it? Personally, I'm disappointed. I expected there to be real, substantive debate over this legislation, but instead we're reduced to blowing minor details out of proportion and then inventing imaginary scenarios under which they become literally life-or-death issues.

This isn't the fault of conservatives. This is the fault of a minority of conservatives who push an agenda of deception and "big lie" propaganda. Don't get me wrong; they're not alone. There are a minority of liberals who enjoy exactly the same tactics. The problem is that neither one of these groups represent the majority of Americans, and we really need to demand that they shut up and let us be heard over the din of their trial-by-shouting form of debate. There are some very smart people capable of propelling this debate forward in useful ways, but they don't get a chance to be heard because they say boring things like, "of course the U.S. should have a baseline of healthcare like every other developed nation in the world, but we need to decide if we want to model it on one of the dozen or so systems that are working out there today, or if we need something unique, and if so what. Then we need to get to work on the hard part: transitioning all of our spread-out healthcare programs into the new plan so that we don't just make the problem worse." See? That has no media "zing." It just doesn't sell. So instead, we have an ill-considered rush to push forward a single, probably flawed plan before anyone can build up enough shouting to get it stopped.


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